Page 19 - Aegion PPO SPDs

Medical Care Buy Up Plan Core Plan Savings Plan

 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Oral Surgery
(Includes removal of impacted teeth.
Dental anesthesia is covered only if
related to payable oral surgery.)
 Network
10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible
 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Orthotic / Prosthetic Devices
(Includes initial glasses or contact
lenses after cataract surgery, foot
orthotics, wigs and toupees based on
Medical Necessity. Toupees and/or
wigs are limited to one each benefit
year.
 Network
10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible
 Out-of-Network
30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

Other Outpatient Therapy Services
(Includes biofeedback and blood
therapy. Biofeedback in office
setting is subject to Copayment.)

 Network 10% Coinsurance, 20% Coinsurance, 30% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

 Out-of-Network 30% Coinsurance, 40% Coinsurance, 50% Coinsurance,
After Your After Your After Your
Deductible Deductible Deductible

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